National Kidney Foundation of Michigan Mission: to prevent kidney - - PDF document

11/12/2019 1

Using the Bridge Application to Increase Referrals to the Diabetes Prevention Program

National Kidney Foundation of Michigan

Mission: to prevent kidney disease and improve the quality of life for those living with it

The DPP and Solutions Needed

• Educating both Physicians and the Public
• Seamless integration with Practice Workflow

and Patient expectations

• Constant coordination of information

11/12/2019 2 What is prediabetes?

• In general, a blood test

shows that a patient is nearing the type 2 diabetes range.

• Patients are at high risk

for developing type 2 diabetes without intervention

• Best intervention:

Lifestyle Change!

• Fairly recent scientific

consensus on the prediabetes diagnosis

Educating both Physicians and the Public

• Huge hurdle in connecting providers to

“prescribing” a program like the DPP.

• It is a year long.
• Results are measured over time. ROI is not

conveniently apparent in the near term.

• Not necessarily as simple as medication-only

interventions.

• The NKFM is a community-based organization, not

within the typical ACO/care system.

• Patients typically don’t fully comprehend,

sometimes don’t hear, a prediabetes diagnosis.

• “Blood test was ‘bad.’”
• “My sugar was off.”
• “Why is a ‘kidney non-profit’ calling me?”

Seamless Integration with Practice Workflow

• NFKM reached out to

Practice Managers and Referral Coordinators, identifying the common tool of the Bridge Application.

• Hosting Practice

Education about Prediabetes, and highlighting direct linkage to NKFM through the Bridge Application.

11/12/2019 3 Seamless Integration with Patient Expectations

• NFKM staff connect

with potential

participants, citing

specific provider referral in the Bridge

Application.

• NKFM provide

immediate, direct

feedback to Practice Managers about

patient registration and health journey.

Constant Coordination of Information

• Our Program Team records

progress of outreach phone calls, emails or home visits to referred patients using the Bridge Application.

• Our Referral Team can

immediately update providers about patient progress through the registration process and workshop progress.

• Our Analytics Team will provide

data feedback on outreach, class attendance and health

• utcomes, using the Bridge

Application as cross-reference with our own proprietary database.

Resources

• ReadySetPrevent.org
• NKFM.org

11/12/2019 4

Questions?